Health (Homes for Incapacitated Persons) Bill, 1963—Second Stage.

Question proposed: "That the Bill be now read a Second Time."

Minister for Health (Mr. MacEntee)

Earlier this year, in the course of a debate in this House on the need to regulate the manner in which elderly, sick or infirm persons were maintained in premises commonly and loosely referred to as nursing homes, I announced that it was the intention to introduce legislation to confer on health authorities powers in respect of places of the kind, and to enable the Minister to regulate the standards of care provided in them. The present Bill proposes to give effect to that intention. Subject to certain specified exceptions, it provides broadly that where more than one incapacitated person is being maintained for private profit, the person in charge of the premises must notify the health authority in whose area it is situated of the fact; and the health authority, being thus notified, will be empowered to inspect such premises in order to ascertain that the conditions obtaining in them comply with regulations made by the Minister for Health.

We do not have full information about such premises, nor how many incapacitated people are maintained in them. There is no reason to doubt, however, that the number of the latter is not insignificant. Where such persons are properly tended and cared for, those who undertake the task provide a useful service. Therefore, where their obligations to those in their charge are fulfilled reasonably well — and in this context I would like to stress reasonableness cannot be assessed without reference to what patients or their relatives can afford — the State should not interfere. In the course of the debate to which I have referred some Senators evinced suspicion and anxiety that the care and attention generally given falls short of what it should be; and no doubt in this they reflected the views of others. The purpose of this Bill is to remove so far as may be, all reasonable occasion for such anxiety and to give health authorities powers which should enable them to eradicate abuses where they exist.

I would now like to mention a few things that the Bill does not purport to do.

First, I should make it clear that registration of nursing homes is not provided for. Under a system of registration the proprietor of a home would have to apply to the health authority, which would then be called upon to inspect and register the place before business could be carried on. But I suggest that the important things which should be considered when determining whether a home of this kind should be permitted to carry on are not so much the amenities attached to the premises, but rather the human qualities of the staff; the kindness, care and attention which they extend to their patients, and which is reflected by these in the degree of happiness and contentment which they manifest in their environment. Moreover, with a system of registration the description "registered" could be included in the title of a home. This might be taken as implying that because the undertaking had fulfilled certain rigid standards—and rigidity is the last thing we want in dealing with this problem —a special seal of approval had been conferred on it by the health authority.

Secondly, Senators will note that nowhere in the Bill is the term "nursing home" used. Some of the premises which it will cover could, perhaps, be legitimately described as nursing homes, that is premises in which professional nursing is provided, but not all of them are or, indeed, need be of such a standard; so that it would be inappropriate to designate such places as nursing homes and misleading to allow them to apply the style to themselves.

Accordingly in directing the preparation of the Bill, I laid it down that a fair degree of elasticity in administering it should be provided for and that the minimum standards prescribed under the Bill must not be such as to put out of business any home in which accommodation, feeding and care suffice for the frugal comfort of those staying in it. If an attempt were made to impose higher standards very many undertakings which meet in a reasonably satisfactory way the needs of an invalid whose family circumstances are modest would be faced with the option of closing down or making their charges prohibitively high. I am sure that those who have been anxious that something should be done in the matter of such homes would not desire this.

And now for the details.

Section 1 defines the premises to which the Bill will apply. It will be noted that there are exemptions in certain circumstances. There is, for instance, an exemption in respect of the maintenance of close relatives, as defined in the section. Then there is the case of the home where, say, the proprietor was a trained nurse and, having the necessary skill and perhaps free time, she agreed to take in an incapacitated friend on the understanding that the latter would pay for the care and attention she got there. To meet this case, a home where only one person is kept is exempted. Maternity homes obviously had to be excluded from the provisions of the Bill, since there is an effective system of registration and control in respect of them under the Registration of Maternity Homes Act, 1934: the same is the case also with institutions for the care of the mentally ill, which are already subject to surveillance under the Mental Treatment Acts.

It will be noted that Section 1 also provides that the measure will be construed with the Health Acts, 1947 to 1960 and, in particular, that a reference in the Health Act, 1947, to that Act will be construed as including a reference to the new Act. These are most important provisions. By reason of them it will be possible to apply to premises covered by the Bill the adequate powers of inspection of premises which health authorities and their officers already have for the purpose of enforcing the Food Hygiene Regulations and other enactments relating to-health.

Section 2 specifies the matters on which the Minister may make regulations. These may include the numbers and qualifications of staffs, the design, maintenance, repair, ventilation, heating and lighting of the home, the amount of space in bedrooms and wards, washing facilities and sanitary conveniences, the quality of the food served in the home and the standard of cleanliness. This list may appear intimidating, but I would repeat that it is not my intention that the standards prescribed should be excessively difficult to reach. Contravention of a provision of the regulations will, however, under sub-section (3) of this section, be an offence punishable by substantial penalties: in addition to provision for fines and imprisonment, there is to be a power for the court to disqualify a person convicted of an offence under the Act from carrying on, or taking part in the management of, a home for the incapacitated.

Section 3 provides for the notification to health authorities of the names and addresses of homes to which the Bill applies and of the names of the persons in charge of them. This will apply both to homes in operation when the Bill becomes law and to new homes opened thereafter. It is hoped, by the operation of this section, to ensure that the health authority will be fully informed of the existence of all homes in their area.

Some concern may be felt for the home where, upon inspection by the health authority's officer, it emerges that conditions are not all that they might be. The proprietor of such a home may be quite willing to rectify defects, if reasonable time were given for him to do so. Since the initiative in taking prosecutions for offences against the provisions of the regulations will, under Section 4 of the Bill, rest with the health authority, it may be assumed that the health authority in such a case would allow the proprietor of the home such an opportunity.

Many elderly, infirm or other incapacitated persons who cannot be cared for by their families, need no special nursing care apart from some little assistance in the ordinary physical functions. One thing, however, must be assured to them, their food must be kept fresh and uncontaminated and handled and served with no less consideration for standards of hygiene than is demanded in the case of hotels and boardinghouses. Under Section 5 of the Bill, the provisions of Section 64 of the Health Act, 1947 will accordingly be applied to those premises to which the Bill applies; so that those concerned with the preparation, keeping and serving of food in them will be required to comply with the appropriate provisions of the Food Hygiene Regulations.

Section 6 of the Bill is a saving clause in respect of the care and treatment of persons who are mentally ill. It is aimed at ensuring that, though a person who is—to use a homely word —"bothered" may be maintained and cared for in a home of the type with which this Bill deals, there will not be conferred on such homes any right to receive or care for a person suffering from a mental illness which should properly be treated in a statutorily approved mental institution.

Under Section 7 regulations made under the Act must be laid before each House of the Oireachtas. Since the livelihood and freedom of individuals conducting these homes might be affected by the conditions imposed upon them under the regulations made under Section 2, it is important that the Houses of the Oireachtas should have the opportunity of seeing and approving of these conditions before they become obligatory under the law.

I recommend the Bill to An Seanad for a Second Reading.

Miss Davidson

The introduction of this Bill gives some hope for our desperately sick and for our aged citizens. I thank the Minister sincerely for bringing in the measure and I am sure he will forgive me if I say that I feel proud that my efforts and those of my colleagues to get such a measure on the Statute Book contributed in some degree to the decision he has taken. In any case, I offer him sincere and genuine congratulations. If there had been provision in the Bill for registration it might have been described as a charter for the helpless. Due to the publicity following the earlier discussions on the subject many of these alleged homes have already been cleaned up and made somewhat more cheerful but much has still to be done. All these reforms hinted at in the Bill still require to be done from the patients' point of view. Food is still inadequate, skilled attention is absent, the new look has not yet reached the inmates. With this Bill, with the Minister's further co-operation we might be able to measure our standard of civilisation by the condition of the less fortunate of our citizens and stand before the world with our heads erect.

The points set out in Section 2 (2) (a) to (f) inclusive seem to cover much of what is necessary to approach the problem of the inmates of these homes. I should like to hear the Minister enlarge somewhat on paragraph (b) of the section which refers to the qualifications of staffs of the homes. Will the Minister require proper nursing qualifications or will his regulations put an end to the prevailing practice of dressing up untrained persons and giving them the title of nurse or matron and so forth? I should also like the Minister to state in his regulations the ratio of trained, qualified personnel to the number of patients. Another point to which I should like to refer is that, generally speaking, there is no regular visit of a doctor to these homes. He is only called in when there is an emergency. It should be necessary that when any person has to administer drugs, even ordinary sleeping tablets, it be done only under medical direction and by a person who would understand the strength and effect of the substance being administered.

The source of supply and the stocks kept on hand should be registered and this register should be open to inspection. The Minister felt that I exaggerated in my reference to stocks of sleeping tablets kept in some of the homes but I can assure him I did not. At column 775, of volume 56, No. 9 of the Seanad Debates the Minister said, referring to me:

She has told us about barbiturates in a bottle, quite forgetting to remind the House that barbiturates can be supplied only on a prescription and that the supply of them is very carefully controlled.

I do not want to bring the Minister thundering down on my head again because I fully appreciate what he has done in introducing the Bill but I should like him to make sure of his information in regard to barbiturates. What he says is in effect what the position should be but is it the position existing at present? As an example of why I am so worried about this question of barbiturates let me quote from the Irish Press of 23rd May 1963, just about six weeks after the Minister wiped the floor with me for what he felt was my lack of correct information in regard to the availability of drugs. The report in question gives details about an unfortunate woman whose death, according to the coroner, was due to barbiturate poisoning. This poor creature, described as being of no fixed abode, had taken sufficient tablets to cause her almost immediate death. In her handbag were found 20 capsules and 75 tablets and in her room in the house in which she was employed two further bottles of barbiturates were found. Surely this poor woman did not get her large supplies of barbiturates from “a carefully controlled supply”. I make this reference merely to impress on the Minister that there must be some source from which these substances can be got without control and that this source should be traced and closed up.

I confess to being disappointed at finding that the aim of the Bill is not to register these homes but merely to give the Minister power to make regulations to bring about reforms. As we all know, a Minister need not act under the powers or he might make inadequate regulations and the only redress the members of the House would have would be to annul the regulations when they are eventually presented. I do not think we have power to amend them. I do not believe for one minute that the Minister proposes to ignore the regulations when he has made them but I can see no real reason why he should not write specific regulations and requirements into the Bill so that we could all help him to improve the measure rather than have the House pass a mere skeleton Bill and then find the regulations inadequate or find, at some date, a Minister not willing to see them through.

The success or failure of this Bill, to my mind, rests on the questions of inspection and supervision. Therefore, Section 2 (2) (g) troubles me a bit. It says that among the things the Minister's regulations will do is to "(g) provide for the enforcement and execution of the regulations by health authorities and their officers."

Would the Minister say (a) if there are available in the local authorities, officers who could be allocated to this work; (b) would such personnel have the necessary training and the experience to enable them to assess the condition of patients, the adequacy of their diets and treatment, the cleanliness of the premises, including the kitchen and food preparation quarters, and also be able to judge whether, in general, the inmates were being properly cared for, and (c) would there be any provision that a person or persons authorised to inspect the homes would be enabled to interview in private any person in the home for the purpose of investigating any complaint as to his or her treatment or where the inspecting officer himself had reasonable cause to believe the person was not receiving proper care? A visit, say, to the carpeted reception area of homes would serve no useful purpose. The actual patients' rooms must be visited and if they were visited around mealtime so much the better.

I have made some inquiries regarding inspections. I find that, while the Minister has power to appoint officers in the local authorities for certain inspection duties, in some authorities at least there have never been any such specific appointments made and such visits and inspections as are made are generally carried out by "visiting commitees." So far as my information goes these visiting committees are committees such as visit prisons and so on. I particularly want the Minister to realise that I am not using this reference to inspection officers or visiting committees in any slighting manner but only to direct his attention to the fact that such inspecting officers would need very special training if they are to do what I believe the Minister wants done — in relation to subparagraphs (a) to (f) of Section 2(2) of the Bill.

I referred briefly on an earlier occasion to the British Nursing Homes Bill which was an extension of existing legislation there. I should like to refer to part of the discussion which took place on that Bill when it was before a Select Committee of the House of Commons. The following is an extract from the report of the Select Committee of the House of Commons dated 23rd January, 1963, at column 5. Mr. Kenneth Robinson, Labour M.P. for St. Pancras, said:

It is clear ... that the existing regulations are inadequate or that they are not being, in all circumstances and in all areas, properly discharged by the local authorities on which the responsibility for the inspection and control of these nursing homes lies. It may well be that local authorities have not the staffs necessary to do the job. If this is the case, this Bill may go only a very small way towards rectifying a situation which I think has been revealed as being altogether unsatisfactory in many respects...

Discussing the problem further, in the same report, as reported at columns 8 and 9, Mr. Norman Dodds, Labour M.P. for Erith and Crayford, said:

I welcome this measure as being a step in the right direction. But we should be "kidding" ourselves if we believed that a satisfactory solution to the problem can be provided by this Bill.

My Hon. Friend, Mr. Robinson, said that much of the present dissatisfaction exists because local authorities do not possess the necessary staffs to undertake proper supervision.... There are too many elderly people to be accommodated by the existing nursing homes. Local authorities are aware of the severe limitations of some of the homes but they are also aware—as this Committee should be—that there is no other accommodation available for the patients in those homes...

He continues:

I suggest that the Government should take a lead in providing a solution to the problem. It is wrong to suggest that the local authorities are fully to blame, for the problem is too big for them to tackle. The matter must be dealt with before it is too late. I suggest that such a course of action might be regarded as a form of "insurance" because some Hon. Members may one day find themselves in need of such accommodation... I support the Bill but let us go on to something which is bigger and better...

In a later discussion of the Nursing Homes Bill in the Standing Committee, Mr. Kenneth Robinson, M.P., used words which I think are worth repeating. They are as follows:

This measure represents a valuable potential safeguard. It is potential only so long as local authorities have inadequate staffs, as is the case with most local authorities today. Staffs are inadequate in number, qualifications and experience. Since this Bill empowers the Minister to lay down regulations, there is clearly a responsibility upon him to see that his regulations are complied with. I hope we shall receive an assurance ... that unless the Minister is satisfied that inspections are being properly carried out, he will use his powers to see that the local authorities obtain the necessary personnel to carry out inspections...

I have used these quotations to help the Minister to appreciate the difficulties which the members of the House of Commons met in a country where most nursing homes—and homes for aged people—were already registered— the Bill being discussed was merely to extend the scope of existing legislation.

I should like to ask the Minister if it is the intention that inspection would be carried out without any previous warning to the owners or persons in charge of the homes—spot inspections. I think such procedure is essential if the maximum results are to be achieved. It should be impressed on all inspectors that they do not, as I said earlier, remain in the reception area but enter into the patients' rooms, into the kitchen quarters and, if possible, to time their visits to coincide with meal hours when they could inspect the patients' food.

Another question I would ask is this. Will homes have regularly to send in details showing the number and ages of the patients? Will regard be taken of room temperatures? Will precautions be taken against fire? Will notice be taken of fire escapes, floor coverings, screens, night services, and so on? Will any form of registration certificate be issued stating the number of patients who may be accepted into the home?

Perhaps it would help the Minister to appreciate my misgivings about some points in the Bill if I mention the difficulties experienced by a local authority which came up against grave difficulties in dealing with unsatisfactory homes for aged and disabled persons and which overcame these difficulties by promoting its own Private Members' Bill. That Bill is now known as the Hertfordshire County Council Act, 1960.

As Senators probably know, Hertfordshire is an area of England where there is a lot of residential development within reach of London. It has tended to have a large number of nursing homes and old persons' homes privately run. The county council found that some of the homes were unsatisfactory and that standards were poor. The management, in some cases, were completely unco-operative and in these circumstances it was difficult for the council to do anything. The homes were registered under the National Assistance Act, 1948. While these Acts provide for a person to be registered to run a home, they do not allow for conditions to be attached to a registration and the only remedy in the case of an unsatisfactory home was for the council to cancel its registration. There was, however, an appeal to the magistrates' court.

Cancellation of registration was considered an extreme remedy: not only did it deprive proprietors of their livelihood but, more important, it had the effect of turning out of the premises a large number of old and sick people who had no other place to go. There was the difficulty also that whilst it was one thing for the medical officer and the social worker to be certain that the home was unsatisfactory, it was very often a completely different thing to be able to prove it in a court of law to the degree that the extreme remedy of cancellation of registration should be upheld in that court.

The Hertfordshire County Council felt, therefore, that what was needed was a provision which would enable a registration to be granted subject to a number of detailed conditions designed to establish and secure the maintenance of reasonable standards within the homes in question. This they did by having their Private Bill passed into law and incorporating their conditions of registration in certain sections of the Act. A breach of any condition amounted to an offence punishable by a fine in a magistrates' court.

The Clerk of the Hertfordshire County Council, Mr. Neville Moon, said in October of this year, that as a consequence of the passing of their Act—and I quote him—

We have had a firmer control over private homes in the county and any new applications for registration have been tied up most carefully with properly designed conditions.

It might be no harm for me to add that in August this year the British Minister of Health made regulations under the Nursing Homes Act, 1963, which deal with the problem nationally in much the same way as do the appropriate sections of the Hertfordshire Act, in that they lay down standards to apply to all nursing homes and to provide that a breach of any particular standard leaves the management of the home open to prosecution.

I would make an appeal to the Minister on this measure and at this stage, when it would be easy for him to do so, to follow the good example of Hertfordshire County Council and, instead of relying on regulations, to write his specific requirements into the Bill and make it a bigger and a better Bill than that we have before us.

When I was seeking information concerning the needs of our aged and incurably ill people, there was always the shadow which lay over the scene. It was agreed that extensive reforms were needed but the question to which the Minister has already referred was how far could we go before we priced the refuge beyond the means of the sufferer and his family? That is where I would repeat the British Labour M.P.'s words: "The Government should take a lead in providing a solution to the problem." I think the Government can do this. Tuberculosis is today, happily, almost a thing of the past. Great institutions were built to deal with that scourge. They are not needed any more, thank God. Newcastle Sanatorium and soon, I think, Blanchards-town, will be unoccupied. Could not these fully equipped hospitals be used to take a very large number of our aged and incurable citizens, keep the staffs in employment, relieve the pressure on private homes and reduce the temptation to overcharge for skimped services?

I am always interested in new employment openings. The need for the right type of inspection staffs set me thinking on how that problem might be met. There are very many young people anxious to enter the nursing and medical professions, most of them well educated. Competition for entrance to the medical schools is very keen and most of us will know of young persons who have failed to get a place because they could not quite make the grade in, say, French, mathematics or some other subject. We also know many good doctors who have not a word of any foreign language and who are poor enough at other non-medical subjects. The young people to whom I refer would, in many cases, find a useful and rewarding career if they, with their leaning towards medicine, were trained not to practise medicine or undertake nursing duties, but trained to know and appreciate what was right treatment for sick persons, what constituted proper hygiene and cleanliness in hospitals, nursing homes, what was adequate sanitation, et cetera. These young persons would not displace any of the necessary nursing and/or medical staffs. Their new occupation would constitute an outlet for Irish youth with a desire to work among the sick. They would become a hospital inspectorate service which, after full training and under Government or Local Government control, would in due course provide the staffs necessary under Section 2 (2) (g) of the Bill we are discussing. They would be the officers to ensure the enforcement and execution of the things necessary to make the Health (Homes for Incapacitated Persons) Bill much more satisfactory.

To be effective, the contemplated inspection staffs will need to be active and energetic. There will be much climbing up and down stairs if their job is to be done properly. Every part of the establishment must be looked over. How often have we been struck by the beauty of the rooms and appointments of an ocean liner only to be shocked by an outbreak of discontent among the crew because of the dirty, insanitary, over-crowded accommodation allocated to them in the floating palace? How often, too, have we admired the tasteful refinements of hotels to be horrified when labour discontent highlighted the far from acceptable conditions prevailing in the staff and kitchen quarters. I often wonder how many boards of directors, discussing the affairs of their industries, make it their business to go down and see the conditions under which their lowest grade workers do their jobs.

An Cathaoirleach

I am afraid the Senator is now getting away from the Bill.

Miss Davidson

I was going to say that the same thing would apply to institutions and the boards of directors that run them. I was wondering if such boards of directors, or members of such boards, ever leave the elegant boardroom to nose around wards, workshops and kitchens where the real functions of the institution are being performed. After all, we do hear many grumblings concerning things that could easily be rectified by adequate inspection staffs or vigilant boards of directors.

Before concluding, I would again like to stress the views of the members of the House of Commons, when discussing their Bill, and to say it is my belief that at the moment our local authorities have not the inspection staffs available with the special training necessary, and the available time, to take on this extra work of inspection under this new measure.

I notice in Section 1 (1) line 19 at (a) that premises in which no incapacitated person is maintained for private profit are excluded and not subject to inspection. Would the Minister say if this means that a home run by a charitable organisation would be excluded? What prompted me to ask the question is that surveys made by a team from the London School of Economics, who inquired into this problem, have shown that on the whole the best care of old people has been in the voluntary and charitable homes. All of these homes, however, might not be of equal excellence and, indeed, some of the institutions might be glad of guidance. I am sure such institutions would have no objection to inspection. I should just like to hear the Minister's views on that point.

I hope the Minister will give consideration to the points I have mentioned and, where possible, meet me on them. I would repeat my congratulations and thanks to him for introducing the Bill, and express the hope that as a result of its passing a horrible blot will disappear from our national life.

Professor Jessop

I should like to join with Senator Miss Davidson in congratulating the Minister on having introduced this Bill. I do not propose to go into the Bill in the detailed manner in which Senator Miss Davidson dealt with it. She has obviously given us a full review of requirements in relation to the system of inspection, the desirable standards in various regards and so on. I do not think there is any need for me to cover that ground.

I have two reservations about this Bill. The first, as has already been voiced by Senator Miss Davidson, is in relation to registration. I think it would be more satisfactory if the Minister could see his way to have some system whereby there would be a list of recognised nursing homes or recognised homes for incapacitated persons, if you like to put it that way, and not leave the position so much in doubt as I think it is now and will be in the future. There is provision in the Bill that anybody wishing to start such a home has to inform the local authority and get recognition for the premises in which this home is to be run. I do not see how this avoids the difficulty the Minister mentioned of having a certain amount of official recognition for that particular home. I do not see that there is any great difference between the home that has been started anew and one that already exists in that regard. Such conditions do not apply to the home already existing. In any case, how is the local authority to know about those already in existence? There is now no list of nursing homes, or any other kind of homes, for incapacitated people. It is very difficult if one has to tell medical students about these places. For instance, it is a matter of research to find out how many there are in Dublin.

From the point of view of assessing their standards and the form of regulations the Minister is going to lay down, we are starting with the difficulty of not knowing where to send our inspectors. In fact, we have to wait for complaints. There are some who send complaints to the local authority and then the local authority can send the inspectors around to find out what is the nature of the complaint and have a general look around.

I do not know what is the position about those in respect of which complaint has been received, nor do I feel that because no complaint has been received, one can assume that everything is in order. There are many incapacitated people who do not know when they are not being cared for. Many do not know when they are being underfed. Medical people constantly come across cases in which the only complaint is insufficient food and the patient is unaware that this is the only thing that is wrong. If that condition exists in a home of which the local authority has no knowledge and in respect of which no complaint has been made, then I do not see what is going to be done about it.

The Minister said in the debate on Senator Miss Davidson's motion in volume 56, column 792 of the Seanad Debates that there would be an arrangement for official intervention in cases where there is reason to believe conditions are unsatisfactory. Could the Minister tell us the circumstances in which there is reason to believe "that conditions are unsatisfactory"? I think this is difficult. Therefore, I think all this will disappear if there is a list of those places and if they are, in fact, registered.

The second reservation I have is in relation to the definition of incapacitated. The Bill says:

"incapacitated", in relation to a person, means suffering from—

(a) physical infirmity or a physical injury, defect or disease, or

(b) mental infirmity or a mental handicap

that renders the person incapable of looking after himself;

Am I in order in referring to old people who are not, in fact, incapacitated according to that definition? There are many people in this country, and in all countries, who are not able to look after themselves but who could not be said to be suffering from "physical infirmity or a physical injury, defect or disease, or mental infirmity or a mental handicap". This is a section of the population that we have to consider. Everybody knows that the old people in the population constitute an increasing problem for two reasons. There are more of them because people live longer on account of the more effective treatment for diseases from which they died formerly. They also constitute a problem because the family is less able to look after them. The absence of domestic help, the increasing tendency for mothers to have some kind of gainful occupation, are factors which make it impossible very often for an elderly person, even when he is not disabled, to stay at home. I think these people are a problem and if they do not come under the definition in this Bill, then I suggest the Minister should think of some means of covering them either in this or some other measure.

Mr. Ted O'Sullivan

I am sure the Minister has satisfied himself of the necessity for this Bill. As far as I know at any rate in Cork and the south generally there is no necessity for it. Our big problem is that we have not got the nursing homes suitable for accommodating people of this type. We have, of course, our county homes in west, south and north Cork. There is St. Joseph's and St. Patrick's for very sick people, and St. Kevin's.

I do not know of any homes in Cork, city or county, on a par with the homes here in Dublin described by Senator Miss Davidson and the Minister as requiring this legislation. Our big trouble is that there is not sufficient accommodation for people who are senile and cannot look after themselves with the result, as everybody knows, that our mental hospitals are over-crowded with people who, I think at any rate, are not fit cases for a mental hospital, people who do not require restraint but who yet are unable to look after themselves. If we had more nursing homes, in the South at any rate, to cater for aged people we would be better off. There is a big demand at the moment for homes to cater for those people. The time will come when these homes will have to be established, when the county home and these places to which I have referred are overcrowded. Then people must turn to private nursing homes to get accommodation and the private nursing homes are not there. Then the cost of maintenance in a private nursing home is beyond the capacity of ordinary people. Only people with considerable private means can get this accommodation, but when these private nursing homes are inspected and passed by the health authority is there any reason why the health authority should not contribute something towards the maintenance of people with smaller means? If they were maintained in the county home or in a mental hospital the health authority would pay for them in full. If they have slender means and can contribute something in a private nursing home then the health authority should also contribute something.

However, our big trouble in the south is that there are not sufficient nursing homes to cater for the aged and mental hospitals are overcrowded. For that reason we do not see any necessity for the Bill so far as that part of the country is concerned. I realise from what I have heard from the Minister and from Senator Miss Davidson that there is a necessity for it in Dublin and if there is I am sure the Bill will deal with it.

Professor Stanford

Speaking on the Bill, I should like to direct my remarks almost entirely to the problems of old age and especially to the people who are incapacitated through old age. This is clearly a growing problem in all our Western civilisation. I quote a research worker in the field, Dr. Martin Gumpert:

"Around 1800 we discovered the Rights of Man. Around 1900 we discovered the child and his rights and we have done much good and some bad to make up for our previous neglect. We should not have to wait in this accelerated century until the year 2000 to discover the aged and their rights.... We can do it here and now."

This problem is going to face us more and more as the Minister well knows in this country. Further, it happens that in this country the proportion of aged people is higher than in many other countries in the Western world. There are two reasons mainly for that: one is emigration of our younger people; the other is the fact that Irish people on the whole live longer than people in more hectic countries than our own; to quote one piece of statistics, the proportion of old people, people over 65 in 1959, was 10.7 per cent here, and in the United States it was 8 per cent.

In this country we are going to have more and more people incapacitated through old age. On the other hand, the existing provision in hospitals and homes of various kinds is undoubtedly not up to the standard of many of our neighbouring countries. Dublin Corporation has done a certain amount. Recently we had a private Bill from the Iveagh Trust to set up a home for elderly people near the canal in Rathmines. Many religious and secular bodies provide homes on a voluntary basis. On the whole, however, the provision is totally inadequate, and there will be more and more demand for some kind of provision for elderly people.

As Senator Jessop said, it is not easy to draw the line between "incapacitated" and "not incapacitated," and I would ask the Minister to consider the definition once again. It would be very hard to say in certain cases that this or that old person is fit to look after him or herself, or not, and I would like to know what the Minister has in mind regarding the meaning of "incapacitated" here. Will people who are senile but who are not suffering from a definite physical infirmity, injury, defect or disease come under the Bill or will they not?

On the other hand, as Senator O'Sullivan said, there is a large degree of State responsibility here. These citizens of ours have deserved well of the Republic. They deserve as much care as sick people. This is an urgent and a growing problem. In general, before I turn to the Bill, may I suggest that the Minister consider setting up a commission to inquire into the problems of old age in the Republic? There are some voluntary bodies at the moment who are facing the problems and which are trying to meet them, but I believe they should be faced on a national scale and that a commission of this kind might do very much good. Again, we might need subsidisation on an increasing scale, increasing because, as is generally recognised, the proportion of elderly people will steadily increase.

Turning to the Bill itself, my first complaint is that it is not nearly strong enough, that there is not nearly enough bite in it. First of all, it is simply permissive. We read in one section "the Minister may" that, I am certain, should for the good of the country be "the Minister shall". It should be a mandatory Bill. I should like to know what the Minister's intentions are if it remains "may". I should like to hear why he has not used the stronger word.

This Bill in other words, only promises action on a matter to which the Minister's attention has been repeatedly drawn over many years. Nothing may come of this clause of the Bill so far as I can see if the Minister does not decide to act. I would appeal to him to consider changing that "may" to "shall".

Section 1 (a) of the Bill says that the regulation should govern all nursing homes except those which are not run for private profit. I do not think that this is a good exemption. We know that there are many excellent homes run by religious and charitable bodies and that no profit is made, but it may well be — and information I have received tends to make me think so — that there are homes run by bodies of this kind in which conditions are not satisfactory. That may be untrue, but it should be looked into, and the only way that can be done is to have inspection and registration of these homes — where charitable or religious bodies through no fault of their own lack funds perhaps — to see that conditions are fit for our elderly people.

I do not like this exemption of premises which are not maintained for private profit. Although run by the kindest and most well-meaning people, sometimes the premises may constitute even a danger to their patients. The law should be the same for all in this matter. This loophole should not be left.

In Section 1 (b) we have an exemption of premises in which not more than one incapacitated person is maintained. Why should one person suffer when two people, say, will not under this law? Why do we not think in terms of one unfortunate person? "If one sparrow falls to the ground", is the phrase in the new Testament. Why should we consider legislation for two sparrows and not for one, so to speak. There could be hundreds of people in separate homes, one at a time, suffering from unsuitable conditions. There may be some administrative difficulty, or other difficulty, but personally I do not like it. I do not think one person should be thrown open to be the victim of any kind of extortion or ill-treatment. I am not saying these things are happening in our country. Some people say they are. I am saying that there is a possibility, and we should legislate against that possibility.

I agree with Senator Jessop and Senator Miss Davidson that all nursing homes should be registered, and that a list of them should be available to the public. I believe, and I think this is what they imply, that no nursing home should be allowed to receive patients unless it is registered. No home should be registered until it has been inspected by a qualified officer as to the suitability of the premises and the adequacy of the staff. I know this is a big question. I know there may be difficulties. But I believe that this is where justice lies. When registration has been effected a certificate of registration should have to be, by statute, visible in the entrance to the home, as has been done in maternity homes. In hotels the same thing happens. Why not here? It would be a good safeguard. Why not include it in the Bill? We should also provide, perhaps not in the Bill, but by regulation, for occasional inspection, as in the case of shops, hotels and schools. Every home should be registered, and every registered home should be subject to occasional inspection. People may say that this might be a grave imposition on fine institutions which do not need inspection. Certainly it would be if it was misused. But how many of our schools which are subject to inspection are, in fact, interfered with in that way? The Minister or his assistants will know when there is reason to suspect a place. When they know that a place is running well the inspection will not be a burden to the institution.

I come now to a final point which was mentioned already by Senator Miss Davidson in her very detailed speech, and one which I think needs emphasising. The administration of sedatives and injections by nonqualified persons is a grave danger. It would be very well, either in this Bill or by some regulation, to forbid that absolutely. If we could go further it would be better still. The best thing would be that every nursing home should have at least one qualified nurse and the proportion of nurses to patients should be laid down specifically by the Minister. The House may think that these are counsels of perfection; I do not think so. When we are passing a Bill like this we should make it as strong and effective as we can. Although the Bill is welcome, it is weak on these points. I should like the Minister to say why it has not got the bite we hoped it would have.

Mr. Murphy

This Bill will probably be known by many of us in years to come as "Senator Miss Davidson's Bill". It is a pity that it has become so incapacitated after handling by the Minister. The Minister has been frank enough to tell us what the Bill will not do and my fear is that people running these nursing homes, about which Senator Miss Davidson and others have been so concerned, will take comfort from reading the Minister's speech. They will say "we are going to be all right; the Minister is not going to be very serious about this matter and we can hope to carry on as we have up to now." Neither Senator Miss Davidson nor anybody else has been saying that all nursing homes are badly run, that the people are badly treated, that the conditions are intolerable. What she and many others have been saying is that some of them are badly run and they are operated by people of bad character. Under the Bill as it stands that situation will continue.

Surely it would only be right and just in this day and age that any person engaging in this business should have to register with the local health authority and that authority should be satisfied that a person is fit to run such an establishment. The Minister was quite right when he said that one of the really important things in running these homes was kindness in the people operating them. Kindness for these aged people is as important as having a skilled person there. What I have been complaining about is the character of some of the people operating these homes for profit. Many families, because of their circumstances, have no alternative but to leave their aged parents in this sort of home. They are not sick enough to be maintained in hospital; they are sent home from hospital. Perhaps the only person in the family has to go out to work every day and the only way of looking after the aged parent once he or she becomes frail is to put that person into one of these so-called nursing homes. Surely the children of these parents, as well as the parents themselves, are entitled to some protection. There should be some authority to say whether these homes are adequate or not. The people themselves are not able to check. When you visit an aged parent he or she, by reason of age, is inclined to be cranky. That is something you must accept. They will complain about anything and everything and the person visiting them is not able to check on the merit of those complaints, whether or not the food is adequate or whether or not the other facilities, such as toilet facilities, are adequate.

I think we are entitled to the protection of the Minister and to have authority in this respect. I agree utterly with the other speakers who say that this Bill is too weak and that, instead, it should provide for the registration of this kind of home.

Mr. Desmond

We all welcome this Bill. It is a very important measure in relation to homes over which we appear to have no control or supervision and in some cases we are not sure where they are located. Although I do not think it is clearly set out in the Bill, it is desirable that there should be a register. Before anybody or any organisation will be permitted to set up a home, I should like to ensure that they will have the permission of the local authority and be registered properly.

I assume that this Bill will apply not only to the types of homes which have been mentioned over which there is no supervision at all but also to hospitals which are operated by health authorities. I also assume that the requirements stipulated in the Bill will apply to these hospitals and institutions.

In some hospitals, in particular some mental hospitals, there is severe overcrowding. Discussions have been taking place in that regard. The Minister is, no doubt, aware of it all and may be waiting to see how the matter will be finalised. Undoubtedly, the conditions of severe overcrowding are being examined. Perhaps some 2,000 patients are occupying space intended for, say, only so many hundreds.

It is not anybody's fault that there is not adequate accommodation but fortunately the matter is being examined. While the position in certain kinds of hospitals has improved immensely — those dealing with what might be regarded as general ailments —hospitalisation for mental patients seems to be a separate problem. Everybody is anxious to see what can be done about it but there is no final decision in relation to some of the hospitals I have in mind to have sufficient and proper accommodation. You can hardly have proper accommodation unless you have the required accommodation and a hospital of the size that is required. If the provisions of this Bill are to apply, it will mean getting down to proper hospital accommodation. Perhaps this measure will speed up the present examination and bring some finality to the matter.

My remarks might also be applied to our county homes where there are many aged and infirm people. Because the amount of accommodation in them is pretty limited, more people go into those other places — with which this Bill is primarily intended to deal.

The matters to which I have referred are not ones for which the Minister can be blamed. The problem that arises is to surmount the difficulties that face us. Furthermore, there is a question of finance involved in this, too. However, it is essential to deal with this because some health authorities at least, have problems in this regard. I do not know the general position throughout the country but it is a serious matter in some of the places with which I am familiar.

Mr. MacEntee

I am grateful to those members of the Seanad who were good enough to express their appreciation of what I have tried to do in the Bill yet some of them do not seem to appreciate what the problem is. This Bill is not designed to deal with recognised public institutions. It is designed to deal with undertakings which exist at the moment and with those which may come into being in the future, where care is provided for people such as given to those who are inmates of public institutions but do it for private profit.

It has been, I think, admitted by Senator Stanford, for instance, that there does exist the problem in this regard of the elderly person who because of age is infirm or who suffers from some physical infirmity or is in some way incapacitated but who, because of family circumstances, cannot be cared for and attended in the family home. Therefore, in order that he may receive even rudimentary attention, such a person must find a place in some home. I suppose the degree of comfort which he will enjoy there will naturally be related to what the patient himself or his family can afford. That is the problem.

There is no use, in relation to that problem, in preaching counsels of perfection. We just have to deal with the fact that there are people who do not want to place their parents or their immediate relatives in a public institution to be looked after at the expense of the ratepayers, who feel that, because of the self-respect of the individual concerned, he himself would hate to go into one of these places. Such people, therefore, have to find somewhere to stay and some persons who for fee or reward, will look after them. That is the problem with which we are dealing.

Institutions have been established to deal with this problem. There are, I suppose, numerous such places — certainly in the city of Dublin — of which the public know very little but which are known to those who have had to avail of their services. The point is, how are we going, first of all, to make the health authority aware of them and where they exist? That is what I am doing in Section 3 of the Bill, which provides that persons who are in charge — mind you it is not the person who owns it — of places where incapacitated persons are maintained for private profit, will notify the health authority. The provisions of that section have been objected to by Senator Jessop and Senator Stanford on the grounds that we are not compelling these institutions to register. The institutions do exist. Supposing we did say that such institutions must be registered, would we not have to have, if we were making that provision in the Bill, some provision on precisely the same lines as there is in Section 3, to the effect that a person in charge of an existing institution must apply for registration, and must, as a practical fact, notify the authorities that he is in charge of such premises?

If Section 3 is defective in respect of premises of the kind covered by the Bill, would not the provision setting up a register and compelling the person to apply to be so registered be equally defective by reason of the fact that unless you do not know that such premises exist you cannot go after the person who is in charge of them and compel him to apply for registration, and compel him, as in this instance, to notify the authority that he wishes to be registered?

Professor Stanford

I thought I might clarify the situation. I should just like to know whether it is possible to make it a penalty not to register?

Mr. MacEntee

I was just coming to that point. It appears to me that the only way in which one can enforce such a provision is to make it an offence not to comply with it. Subsection (3) of Section 3 imposes a very substantial penalty on any person who fails to notify that, in fact, he is in charge of such premises — the person who is in charge, not the person who owns it. Therefore, I cannot see how it should be more difficult to secure notification, and, therefore, to become aware that such premises exist, by the manner in which we are dealing with it under the Bill, than it would be to obtain knowledge that such premises exist, if we were to compel these people to register.

The only advantage of the Bill regarding registration is that it does enable the administration of the Bill to be more elastic — less rigid, than it would be if we were to set up a register and enforce absolute compliance with the prescribed terms before a home could be registered. The important thing I should like to stress in relation to the problem with which we are dealing is that persons who are infirm or incapacitated and require attention, aid and help from other people are more concerned with the human qualities of such people than with the amenities to be found in the place where they are lodged. It is not whether they are going to have foam cushions under them when they sit, or whether they are going to have so many cubic feet in the room in which they live that will keep them happy and contented, but whether the persons running these institutions treat them, and are anxious, willing and enthusiastic to treat them with ordinary human kindness. That is what they want. These people are not ill in the sense that they are suffering from acute illness. They may be suffering from a chronic illness and do require physical care and attention. They are not people who are acutely ill: they are people who only require to be looked after and tended with the same care and kindness as they would expect to be given if they were in their own homes.

There is a wide variety of circumstances to be met with in the ordinary family home. If we are to deal with this problem, which is a pressing one, particularly where there is such a scarcity of help and aid for young people in the existing conditions of our society, we cannot deal with it in a rigid way. I should have thought that any person listening to Senator Miss Davidson's speech would have been convinced that registration in the sense in which it was being sought for here is not the answer to this problem. The British have no fewer than four Acts of Parliament dealing with this problem of registration and I suggest to any Senator who feels that I am in any way wanting in consideration for these people to read Senator Miss Davidson's speech and see what the members of the British Parlament, who have experience of the administration and operation of these four Acts dealing with the registration of nursing homes for the aged and infirm, have to say about the imperfections of their system. I am not saying that what is proposed will produce a perfect system but it is one which is much better adapted to our circumstances than registration would be. Therefore, I think that we shall have to try it out. As time goes on and we become acquainted with the conditions which exist in these homes, we may be better able to plan and formulate the regulations which should apply to them. It may be that we will change, but at worst we are laying the foundation with this Bill.

It was suggested that we ought to have skilled nursing in these homes; that we ought to have a very high standard in them. Most of the people I am providing for in this measure— in fact, the vast majority of them — do not want the attention of professional nurses. They want the same sort of care and attention as would be given to them if they were elderly persons, rich enough to employ a companion. That is the sort of thing which is required. There is no use setting standards which will make it impossible for the ordinary family beset with a problem of this sort to deal with it at all, except by trying to get their aged and infirm parents or incapacitated relatives into one of our county homes, or into homes which are run for charity, homes which are already overcrowded. Let us start with this present Bill and see what emerges from it.

Another thing suggested by Senator Miss Davidson, and Senator Stanford, to some extent, is that there is insufficient control of barbiturates and sedatives in some of these homes. If there is, that is a violation of the provisions of existing statutes. If any person knows that these drugs are freely available they can furnish information to me and I have power under the Health Act of 1947, and other health legislation, to deal with it. But I cannot deal with a vague and unsubstantiated statement that in these places there is general laxity in the control of barbiturates. I can deal with specific cases. Everybody knows we can make laws and that people can break them but you cannot enforce the law unless in some way or other the knowledge comes to you that it is being violated. That is the position in relation to barbiturates.

Miss Davidson

Does the Minister not think that there must be an overall looseness in regard to barbiturates when we see so many cases of overdoses of sleeping tablets?

Mr. MacEntee

I am not prepared to say there is a looseness in relation to these matters. The Senator quoted one instance. I think I have a vague recollection of that case. The unfortunate woman concerned was a person who was quite obviously, if I may say so without any disrespect to her memory, hardened in a certain way of life. We know the circumstances. She had been going from situation to situation. There had been pilfering anyway from some of her employers.

Miss Davidson

There is no indication of that in the report I have.

Mr. MacEntee

The unfortunate lady died in police custody and somehow or other she had smuggled these barbiturates into her cell; she must have been collecting them as she went from situation to situation. She was not an inmate of one of the homes we are dealing with. She died in police custody. On the basis of that incident Senator Miss Davidson wants me to accept it as an established fact that in general in nursing homes or rather in these institutions which call themselves nursing homes — whether they are properly entitled to do so or not I do not know — there is a looseness in the control of drugs. If there is, and any person knows it, it is their civic duty to inform me of the matter or to inform the local health authority so that we may try and put a stop to this abuse. There is no use coming to me and saying the licensing laws are being abused unless you can say: "I know that such and such a person is doing this; will you look after it?" The person who tells me that will be treated very confidentially by me, and to tell me would at least enable me to find one instance. I have not been able to find one where there is justification for and substance in the allegation which Senator Miss Davidson has made.

Senator Jessop took exception to the definition in the Bill of incapacitated persons and he seemed to imply that under it a home in which persons who are merely frail and elderly would be maintained for profit could not be dealt with. I think that the definition of "incapacitated" is fairly wide. It means incapacitated in relation to a person suffering from physical infirmity. I cannot see how anyone can draw the line of demarcation between frailty and physical infirmity. If a person is frail must he not be physically infirm? Perhaps "frailty" and "infirmity" are terms which have a particular connotation for the medical or surgical profession. I thought that the definition in the Bill was wide enough to cover any disability arising from age, physical defect or injury. As I said, we are in any event not dealing with public institutions. We are dealing with places where people have to go, because, if they do not go into these places there is no person to look after them. If the definition is lacking in any way, I would be quite prepared to amend it if, on Committee Stage, some person suggests to me how it can be improved. That applies to the whole Bill. There is no more I can say than that any suggestion offered will be considered. That will be done.

Committee Stage ordered for next sitting day.

Seanad Éireann debate -
Wednesday, 13 Nov 1963